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PM 6-3 o �-&-7a70 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date U/3/I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 3G j oZ-aO REF# <br /> Department of Public Works APN CR# <br /> 71 <br /> G F_ EXP.DATED <br /> VALID /z TO _ / y DRIVEWAYS: <br /> (Applicant Name) STREET 40,A/ CO. " <br /> 5 0 � 0-4-e w a � It/Ul: AREA �Or� QUAD <br /> TYPE <br /> (fMailing A dre s) �j FORMS <br /> C0Yl GDf-U ✓i 6 � NOTES <br /> (City,State,Zip Code) <br /> az 70 —,27z/ 5 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) d��/ <br /> S e g- c�e 4r 7ra <br /> The undersigned hereby applies for permission to%cay+ate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the o e k side of 0. l2 t P o rt, K do approximately /(OO �et'/mile Cas-t_ <br /> of s�'..n c�. _ R.Xp o- -. ,by performing the following work(descripPtion of work): <br /> .t-4tl �E •• as r+�a;h �r-c� do' c i o 't-0 <br /> ( : e-e- /Ka,A+e c W <br /> A ISO ; hC_(uded 0. e +ke- -�- s VC_W <br /> or k w'. L( o.b e SCS <br /> Work will commence on or about 91 j IX----- for approximately_ Aw f 7-- _-dayw <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described abov in cordance w'h the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature 6fApplicant-Title Vate <br /> EIPUMV.WKL4ASTERPSIENCROACHAENTPMWAPPLICATION.DOC(01)06 <br />